During the mid-twentieth century, the British Empire rapidly succumbed to a striking decline. After the Second World War, its colonies in Africa and the Caribbean in particular witnessed a wave of nationalist movements that began to call for self-determination and independence from bureaucratic colonial administrations. Sierra Leone gained independence from the United Kingdom in 1961 after over a century and a half of British rule. After its one hundred and seventy-four years of rule, the British left Sierra Leone with a system of healthcare that was both under-resourced and inefficient after independence. This article will take a historical approach in order to understand the present state of Sierra Leone’s healthcare system, specifically why it proved ill-equipped to handle the horrors of the Ebola epidemic and the status of survivors of the virus in the present day.

In its early years as a new nation, Sierra Leone suffered from the dictatorial rule of several of its initial prime ministers and presidents. Corruption on the part of politicians further diminished the economic standing of the country and continues to do so to this day. Under the rule of President Joseph Momoh in the 1970s, Sierra Leone reached a point where it could not import oil and gasoline, leaving the country without electricity for months at a time.1 Events in both the colonial and national history of Sierra Leone can readily and easily inform the current health of its people and the state of its healthcare system today in the twenty-first century. This article will examine the legacy of both the British colonial healthcare system and the legacy of the Sierra Leone Civil War of 1991-2002.

Diseases such as yellow fever and malaria shaped life and policy in colonial Sierra Leone during the twentieth century. During this time period, the colony grappled with epidemics of fever and malaria during the period between the turn of the century and World War One. Colonial segregation policies in Sierra Leone, enacted as a result of deadly yellow fever and malaria epidemics throughout the eighteenth and nineteenth centuries, proved largely unsuccessful as they were based on scientifically inaccurate information and ultimately disenfranchised Africans even further. Africans were forced to live separately from white colonists, who were afforded special compounds by the colonial government. They were only allowed in the compounds for specific duties such as cooking and other domestic work during specified hours, never during the night.2

During the colonial period, little to no attention was given to the colony’s African population. Colonial administrators such as the prominent health examiner Rubert William Boyce viewed Africans as both harbingers of disease and literal diseases in themselves.3 Mismanagement and underfunding severely undermined education and eradication efforts and the calls of medical experts went largely unheeded. Africans continued to suffer from diseases such as yellow fever and malaria under colonial rule. The legacy of British colonialism and colonial health policy in Sierra Leone continued to leave a powerful legacy even after the colony gained independence and became a republic.

Today, after over fifty years of independence, Sierra Leone still faces serious issues with regard to the health and well-being of its population. The average life expectancy for citizens was estimated to be about 57.8 years of age by the Central Intelligence Agency as of 2015.4 Over seventy percent of the population lives below the international poverty line.4 Diseases such as malaria and yellow fever have been endemic in the country for centuries. The country also suffers from intermittent outbreaks of cholera and meningitis. Much of the Sierra Leonean economy relies heavily on subsistence agriculture. Most healthcare infrastructure is designed for primary health care (PHC) and the country lacks major centers for surgery and emergency medicine. The country houses only three hospitals capable of performing major surgery and laboratory testing, which are scattered across three large cities.

Each of Sierra Leone’s thirteen districts has a health management team comprised of about one hundred technical staff, including doctors, nurses and other medical providers. The team plans and monitors healthcare provision, trains personnel, and supplies equipment and drugs.5 Only about one hundred and sixty-eight doctors were present in the country of over six million people as of 2010—about one for every twelve thousand people.6 The country currently has a free system of maternal healthcare that began in 2010, through which pregnant and breastfeeding women are treated for no charge, along with children under five. The initiative was created in order to reduce the high rates of maternal and infant mortality. However, the country lacks the infrastructure to properly implement the program. In addition, a majority of Sierra Leonean women do not know that they have a legal right to free prenatal care.7 As a result, poorly paid healthcare workers ignore the laws and take advantage of the population’s lack of knowledge by charging incredibly high fees that only few people can afford.7

At the height of the war between 1991 and 2002, many hospitals were ransacked and used as hideouts and strongholds for rebel groups during the conflict. Hospitals that were not used as rebel hideouts were burned completely to the ground.8 The war completely devastated Sierra Leone’s economic and healthcare infrastructure. Over twenty thousand individuals died in the conflict. Rebel groups drew most of their recruits from Liberian refugees who had been staying in Sierra Leone as a result of conflict in their home country and needed food and medical care. Once this tactic failed, rebel groups recruited thousands of child soldiers to join their ranks. Many villages and towns were completely devastated. After the end of the conflict, Sierra Leone had to rebuild much of its infrastructure from the ground up. The country’s main teaching hospital in Freetown was able to stay open during the war, but it suffered shortages of medicines and other essential supplies and equipment, as well as a mass exodus of trained physicians and surgeons seeking to escape the conflict.8

As the war ensued, many people fled the countryside and moved into cities for safety and security. This mass migration into Sierra Leone’s largest cities exacerbated the dire health and sanitation situation in these areas.9 While healthcare services were limited at the time, healthcare centers in areas controlled by the government still managed to provide some services, albeit with fewer workers and supplies. However, provision of healthcare in areas controlled by rebel groups proved much more difficult. Agreements were eventually made between the government and rebel fighters to provide limited services such as child immunization in areas under non-governmental control.9

Besides the loss of human lives and the destruction of healthcare infrastructure, perhaps the greatest health crisis that emerged after the end of the civil war was a surge of mental health issues in response to the conflict. Many Sierra Leoneans continue to suffer from immense trauma after experiencing the horrors of the war. Both rebel groups and government soldiers routinely fired guns in towns and villages. Civilians witnessed widespread killings and the burning of homes and other buildings. People lived in constant fear of attack or death and many had to flee their homes due to the conflict.

Today, a decade and a half later, the number of individuals suffering from mental trauma in Sierra Leone remains unknown, but estimates put it in the hundreds of thousands.10 Statistics taken in 2002 by the Sierra Leonean Ministry of Health and Sanitation placed the rate of severe mental illness at over four times the global average.10 To make matters worse, mental health care in the country is almost nonexistent. Many child soldiers witnessed severe atrocities and former child soldiers suffer from severe mental illness and substance abuse as a result of their trauma.11 The understanding of issues around mental healthcare in Sierra Leone prove vital to addressing contemporary healthcare issues facing the country, as psychological trauma shapes much of the country’s modern history and healthcare issues.

Medical workers transport a recently deceased Eb- ola victim. One of the most dangerous characteris- tics of the virus is that it can be transmitted through dead bodies, making proper care and removal of the dead a priority during the West African epidemic. Source: Global Panorama, Flickr.

The 2014 outbreak of Ebola virus in the country only further exacerbated existing issues present in Sierra Leone’s healthcare system. At the time of the outbreak, it was believed that the virus was not endemic to Sierra Leone, or the West Africa region as a whole.12 However, testing of samples of Lassa fever (an arenavirus endemic to West Africa) from clinical trials revealed that Ebola had been present in Sierra Leone since at least 2006, nearly a decade before the start of the epidemic.13 The Ebola virus affected all aspects of life in Sierra Leone at the time of the epidemic’s height, as immense pressure was placed on a healthcare system that had not been prepared to cope with a healthcare emergency on such a large scale. Many hospitals quickly ran out of beds and many healthcare workers, both Sierra Leoneans and foreign doctors and nurses who came to the country to aid in the relief efforts, either succumbed to the virus themselves or had to be medically evacuated to the United States or Europe for treatment.

The country’s political infrastructure also proved intransigent in its actions at times, as there were instances of politicians taking advantage of the epidemic to further their own means. One well-documented case uncovered a scandal surrounding a shipping container from the United States that had been sitting unopened in Freetown for over two months. The container had been full of $140,000 worth of medical equipment (including gloves, protective gowns, stretchers, and mattresses), whose shipment had been organized by a senior official in the country’s main opposition party. The government of President Ernest Bai Koroma delayed the clearing of the container in order to prevent the political opposition from taking credit for the donated supplies.14 Across West Africa, over eleven thousand people died from the virus, with nearly four thousand of these deaths occurring in Sierra Leone alone.15

The World Health Organization declared the country Ebola-free in March 2016. The epidemic had subsided in the months leading up to the WHO’s announcement, but many flare-up cases had occurred. With over four thousand lives lost to the virus, the country not only faces infrastructural and political challenges, but also socio-cultural challenges surrounding the well-being of both survivors of the epidemic and ordinary Sierra Leoneans. During the epidemic, many Ebola victims were placed into forced quarantine, separating them from the rest of society for days, weeks, or months at a time. At the end of the epidemic, many Ebola survivors returned home from treatment centers only to be chased out of their homes and shunned from their families and communities. Market sellers found difficulty selling their wares as people would not touch them, and many survivors found themselves abandoned by their spouses.16

As serious, long-term outbreaks of Ebola are only a very recent phenomenon (outbreaks before the 2013-2016 West African epidemic were small and isolated), scientific and medical understanding of the disease is still catching up to match the scale in which recent epidemics have occurred. As of now, there exists almost zero public health data on the outcomes and statuses of survivors of Ebola in West Africa, with the 17,000 survivors of the epidemic making up the largest data source on the virus in history.17 It has been found that Ebola has a devastating impact on the brain, with many people hallucinating or falling into comas.17 This impact of the virus on the brain must be taken into consideration when addressing issues around recovery, as Sierra Leone already faces an extreme dearth of mental health care resources, and a significant portion of its population is still left traumatized from the decade of civil war and the recent epidemic. With so little data on survivors of the epidemic, there are a host of potential issues linked to the virus post-infection that have yet to be discovered.

Members of an Ebola awareness group in Sierra Leone. Source: Global Panorama, Flickr.

While a century and a half of colonial neglect and the atrocities of post-independence civil war damaged Sierra Leone’s healthcare infrastructure, there remains hope for the country. The Sierra Leonean government currently partners with various non-governmental organizations such as the Red Cross and a few smaller charities in delivering healthcare to its populace. The primary treatment centers have been restored to their previous states before the war, and continue to receive support in the form of foreign medical instructors and practitioners.17 In neighboring Liberia, the US National Institutes of Health has launched the PREVAIL program, the largest long-term clinical study of Ebola survivors, with smaller studies in Sierra Leone and Guinea. The current state of Sierra Leone’s healthcare infrastructure cannot be blamed entirely on a corrupt and inefficient government. The legacies of colonialism still impact the country today, as the British exploited much of its natural wealth in diamonds and other natural minerals for the sole purpose of bringing them back to the colonial metropole for a profit, while completely ignoring the health and well-being of its native black populations. Today, Sierra Leone must grapple with this colonial legacy, as well as the legacies and traumas of civil war and the deadliest biomedical outbreak it has ever witnessed, as it continues to grow and develop in the twenty-first century.

Elijah Rami is a sophomore in Ezra Stiles College. Elijah is a history major from New York. He can be contacted at elijah.rami@yale.edu.

12 WHO Response Team, “Ebola Virus Disease in West Africa — The First 9 Months of the Epidemic and Forward Projections,” New England Journal of Medicine 371 (2014): 1481-1495. DOI: 10.1056/NEJMoa1411100